PC3088: Pulmonary Hemorrhage and Acute Kidney Injury Secondary to Anti-glomerular Basement Disease in the Setting of COVID-19 in a Pediatric Patient

Introduction: Anti-glomerular basement membrane disease (anti-GBMdisease) is a small vessel vasculitis with antibodies directed against an antigen intrinsic to the glomerular basement membrane and alveolar basement membrane. Since the start of the COVID-19 pandemic, an unexpected number of new cases of anti-GBM disease have been observed. We report the case of a 17-year-old female with a history of altered autoimmune markers presenting with SARS-CoV2 infection, pulmonary hemorrhage, and acute kidney injury found to have rapidly progressive Anti-Glomerular Basement Membrane Disease leading to a fatal outcome.

Case Description: Our patient is a 17-year-old female with a history of altered autoimmune markers, who was fully vaccinated for covid-19 eight months prior, who presented with anemia, acute kidney injury, dyspnea, and hemoptysis. She had a positive SARS-CoV2 PCR on presentation. She initially required oxygen via nasal cannula to maintain adequate saturations. She was managed with hemodialysis, antibiotics (linezolid and cefepime), pulse steroids, and plasmapheresis. Subsequent workup revealed positive anti-GBM, anti-myeloperoxidase (MPO), and normal complements consistent with primary anti-GBM disease. The patient continued to deteriorate, requiring intubation within 24 hours of admission, and despite maximal interventions, including various modes of mechanical ventilation, and renal replacement therapy, she ultimately developed multi-organ failure and died despite resuscitation efforts.

Discussion: Since the start of the COVID-19 pandemic, an unexpected number of new cases of anti-GBM disease have been observed. In a study in the UK, eight new cases were diagnosed between December 2019 and April 2020. This represents a fivefold increase above the background rate of 1.5 per million per year seen previously. However, at the time of the anti-GBM presentation, although IgM and/or IgG antibodies to SARS-CoV-2 were detected in half of the patients, viral RNA was negative. In a case series in adults, patients with positive IgM and/or IgG antibodies for SARS-CoV2 and negative PCR presented with anti-GBM disease and a non-lethal outcome. Similarly to our patient, there is a case reported of a 63-year-old male who presented with respiratory and renal failure in the setting of positive IgM and IgG SARS-CoV2 antibodies with negative PCR and positive anti-GBM antibodies. This patient, similarly to ours, deteriorated rapidly. Cases of anti-GBM have also been reported following SARS-CoV2 vaccination.

Conclusion: Anti-GBM disease is an extremely uncommon disease in children. The initial presentation can be nonspecific, including weight loss, fever, and arthralgia. Since the start of the COVID-19 pandemic, an unexpected number of new cases of anti-GBM disease have been observed. We present the case of a pediatric patient with rapidly progressive respiratory failure with alveolar hemorrhage as well as a severe acute renal injury with the co-existence of anti-GBM disease and SARS-CoV2 infection.